CONFIDENTIALIFP401 State ENG Rev 2/16www.mncourts.gov/formsPage 1 of 4State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: and GuardianshipIn Re: Conservatorship Respondent Ward Protected PersonPetition and Affidavit for Proceeding In Forma Pauperis (Minn. Stat 247563.01; 247524.5-502 ) TO THE HONORABLE JUDGE OF THE ABOVE-NAMED COURT: 1. Under the authority of Minn. Stat. 247 563.01, and upon the Affidavit of the Petitioner filed with the court, the undersigned moves the court for an Order granting the following relief: a. Permitting the Petitioner to proceed In Forma Pauperis without prepayment of filing fee, and certified copy and photocopy fees. b. Directing the District Court Administrator to perform the duties of the office without requiring the Petitioner to pay a filing fee, certified copy and photocopy fees. c. Directing the county of financial responsibility to pay reasonable attorney222s fees for the attorney appointed to represent the proposed ward/protected person. d. Granting such other further relief as may be proper. 2. I have filed the petition to appoint a guardian and/or conservator for the above referenced Respondent. 3. Accompanying this Affidavit or already on file herein is the Petition for Appointment of Guardian and/or Conservator. Said Petition sets forth the Respondent222s address, and other information, to the best of my knowledge.4 a. The Respondent is receiving public assistance under one or more of the following means- MSA (Minnesota Supplemental Assistance) MFIP (Minnesota Family Investment Program);tested programs: American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIALIFP401 State ENG Rev 2/16www.mncourts.gov/formsPage 2 of 4 Food Stamps; General Assistance or Discretionary Work Program; MinnesotaCare, Medical Assistance, or General Assistance Medical Assistance; Energy Assistance; Respondent is represented by attorney5. on behalf of a civil legal services program orvolunteer attorney program, based on indigency.6.. (Include Respondent, Respondent's spouse, minor Respondent's family size is children, and other dependents in Respondent's household, if any. For family size, count Respondent and (list all others): Name Age: Relationship to you The Respondent is receiving public assistance under some other means-tested program:4 b. (Name the program)I have attached proof that Respondent receives public assistance (such as MFIP card or cancelled check from agency) or I will provide proof if requested. The Respondent receives Supplemental Security Income (SSI) as a resource for meeting 4 c.expenses.7. which is less than 125% of the Federal Poverty Line for my family size ofmembers. I have attached proof of Respondent's family income or will provide proof if requested.income is: Respondent's gross monthly income (before taxes and deductions) is8. Respondent's net (take home) monthly income is and the source of that Job/wages Unemployment Spousal Support Trust Income Social Security Other of that income is Respondent's spouse's net (take home) monthly income is Respondent's spouse's gross monthly income (before taxes and deductions) is9.and the source OR, I do not know my spouse's income because:. Respondent's gross annual family income (before taxes and deductions) is American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIALIFP401 State ENG Rev 2/16www.mncourts.gov/formsPage 3 of 4 Respondent is not married.OR10.All other family members and dependents living with Respondent have net monthly income as follows: Name of person Age Net (take home) monthly income Source of Income Respondent receives 11.per month in child support (includes medical support and/or child care support.support and/or child care support.per month in child support (includes medical Respondent pays12.per month in court-ordered spousal support. Respondent pays13.per month for Respondent pays14. rent mortgage payment.The probable cash value and general character of the assets of the Respondent are:15. CashCars, other vehicles (list make, year and equity value ([market value minus unpaid loans]) Real Estate (market value minus unpaid mortgage/loans) Other Real Estate:Other personal property (jewelry, stocks, bonds, etc. list separately)in debt, excluding car loans and real Respondent is presently16.Other factors which support your request are (explain unusual medical expenses, emergencies, reasons that the family money is not available to you, or other circumstances to help the Judge understand your situation):17.estate mortgage/loans. Checking, savings, and credit union accts Homestead:18.I believe that I have good grounds for the relief applied for in this petition for guardianship and/or conservatorship. However, I have been unable to proceed in this matter because the Respondent does not have funds to pay the filing fee, service of process, attorney222s fees for the attorney appointed to represent the proposed Respondent, and other court-related costs. American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIALIFP401 State ENG Rev 2/16www.mncourts.gov/formsPage 4 of 4By signing this Affidavit, I am certifying that these statements are true under penalty of perjury. I understand that if I provide false information on the form it may lead to criminal charges. I understand that failure to execute the form or failure to provide information or requested records may result in denial of my motion to proceed In Forma Pauperis. I am authorizing that the facts contained in this Affidavit may be verified by any means required. Dated: Signature County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address: American LegalNet, Inc. www.FormsWorkFlow.com